Clinical Focus

  • Knee Replacement Arthroplasty
  • Hip Replacement Arthroplasty
  • Arthritis
  • Revision Hip and Knee Replacement Arthroplasty
  • Orthopaedic Surgery

Academic Appointments

Administrative Appointments

  • Chair, California State Registry Committee, American Joint Replacement Registry (2017 - Present)
  • Chair, Central Instructional Course Lecture Committee, American Academy of Orthopaedic Surgeons (2017 - 2018)
  • Annual Meeting Committee, American Academy of Orthopaedic Surgeons (2016 - 2018)
  • Vice Chair, Advocacy Committee, American Association of Hip and Knee Surgeons (2015 - Present)
  • Chair and Medical Director, California Joint Replacement Registry (2015 - 2016)
  • Adult Reconstruction Service Chief, Department of Orthopaedic Surgery, Stanford University Medical Center (2014 - Present)
  • Associate Residency Program Director, Department of Orthopaedic Surgery, Stanford University School of Medicine (2011 - 2015)
  • Medical Director, Total Joint Replacement Center, Stanford Hospital and Clinics (2009 - 2016)

Honors & Awards

  • American Society of Clinical Pathologists' Award for Academic Excellence, University of Vermont College of Medicine (1996)
  • Young Investigator, Osteolysis and Implant Wear Symposium, Orthopaedic Research Society (2007)
  • American Travelling Hip Fellow, British and American Hip Societies (2008)
  • Marshall R. Urist Award, Association of Bone and Joint Surgeons (2009)

Professional Education

  • Board Certification: Orthopaedic Surgery, American Board of Orthopaedic Surgery (2007)
  • Fellowship:Massachusetts General Hospital (2005) MA
  • Residency:Massachusetts General Hospital (2004) MA
  • Internship:Brigham and Women's Hospital Harvard Medical School (2000) MA
  • Medical Education:University of Vermont College of Medicine (1999) VT
  • Fellowship, Massachusetts General Hospital, Adult Reconstructive Surgery (2005)
  • Residency, Harvard Medical School, Orthopaedic Surgery (2004)
  • MD, University of Vermont, Medicine (1999)
  • BS, Yale University, Biology (1994)

Community and International Work

  • Kikuyu Orthopaedic Rehabilitation Centre, Kikuyu, Kenya


    orthopaedic surgery

    Partnering Organization(s)

    Medical Benevolence Foundation

    Populations Served

    Kikuyu, Kenya



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

My primary research interests include: arthritis, clinical outcomes of primary and revision hip and knee replacement surgery, biomaterials, the design of hip and knee implants and instrumentation, and the delivery of health services related to hip and knee replacement.


2016-17 Courses


All Publications

  • Tibiofemoral Dislocation After Total Knee Arthroplasty. journal of arthroplasty Jethanandani, R. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Amanatullah, D. F. 2016; 31 (10): 2282-2285


    Tibiofemoral dislocation after total knee arthroplasty (TKA) is a rare complication. Published case reports describe fewer than 6 patients, making conclusions about the etiology, epidemiology, complications, and treatment of tibiofemoral dislocation difficult. This case series highlights common demographic features, potential causes, and difficulties during the management of tibiofemoral dislocations after TKA.Between 2005 and 2014, 14 patients presented to our institution with a tibiofemoral dislocation. Patients were excluded if they had patellofemoral dislocation or subluxation without a tibiofemoral dislocation. We retrospectively reviewed patient demographics, time to first dislocation, number of dislocations, time to surgical intervention, complications, and potential etiologies of tibiofemoral dislocation.Twelve of 14 patients were female. Their mean body mass index was 33 ± 10 kg/m(2). Thirteen of 14 patients had a mean of 2.0 ± 1.4 dislocations. Four patients dislocated due to polyethylene damage and 5 due to ligamentous incompetence. Twelve of 14 patients required open surgical intervention. Complications in this patient population were common with 3 cases of infection, 7 cases of multiple dislocation, 2 cases of popliteal artery laceration, 1 case receiving a fusion, and 1 case receiving an amputation.Patients with tibiofemoral dislocation after TKA are predominantly obese, female, and have a high risk for complications. They dislocate predominantly because of polyethylene damage or ligamentous incompetence. Re-dislocation is common if treated with closed reduction alone.

    View details for DOI 10.1016/j.arth.2016.03.010

    View details for PubMedID 27084503

  • Obesity is Associated With Early Total Hip Revision for Aseptic Loosening. journal of arthroplasty Electricwala, A. J., Narkbunnam, R., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2016; 31 (9): 217-220


    Obesity affects more than half a billion people worldwide, including one-third of men and women in the United States. Obesity is associated with higher postoperative complication rates after total hip arthroplasty (THA). It remains unknown whether obese patients progress to revision THA faster than nonobese patients.A total of 257 consecutive primary THAs referred to an academic tertiary care center for revision THA were retrospectively stratified according to preoperative body mass index (BMI), reason for revision THA, and time from primary to revision THA.When examining primary THAs referred for revision THA, increasing BMI adversely affected the mean time to revision THA. The percentage of primary THAs revised at 5 years was 25% for a BMI of 18-25, 38% for a BMI of 25-30, 56% for a BMI of 30-35, 73% for a BMI of 35-40, and 75% for a BMI of greater than 40 (P < .001). The percentage of primary THAs revised at 15 years was 70%, 82%, 87%, 94%, and 100%, respectively (P < .001). A significant increase in early revision THA for aseptic loosening/osteolysis in obese patients (56%, 23/41) when compared with the nonobese patients (12%, 10/83, P < .001, relative risk ratio = 4.7).Preoperative BMI influences the time of failure of primary THAs referred to an academic tertiary care for revision THA as well as the mechanism of failure. Specifically, obesity increased in the relative risk of early revision THA due to aseptic loosening/osteolysis by 4.7 fold.

    View details for DOI 10.1016/j.arth.2016.02.073

    View details for PubMedID 27108056

  • Obesity is Associated With Early Total Hip Revision for Aseptic Loosening JOURNAL OF ARTHROPLASTY Electricwala, A. J., Narkbunnam, R., Huddleston, J. I., Maloney, W. J., Goodman, S. B., Amanatullah, D. F. 2016; 31 (9): S217-S220
  • Cytokines as a predictor of clinical response following hip arthroscopy: minimum 2-year follow-up. Journal of hip preservation surgery Shapiro, L. M., Safran, M. R., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Bellino, M. J., Scuderi, G. J., Abrams, G. D. 2016; 3 (3): 229-235


    Hip arthroscopy in patients with osteoarthritis has been shown to have suboptimal outcomes. Elevated cytokine concentrations in hip synovial fluid have previously been shown to be associated with cartilage pathology. The purpose of this study was to determine whether a relationship exists between hip synovial fluid cytokine concentration and clinical outcomes at a minimum of 2 years following hip arthroscopy. Seventeen patients without radiographic evidence of osteoarthritis had synovial fluid aspirated at time of portal establishment during hip arthroscopy. Analytes included fibronectin-aggrecan complex as well as a multiplex cytokine array. Patients completed the modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index and the International Hip Outcomes Tool pre-operatively and at a minimum of 2 years following surgery. Pre and post-operative scores were compared with a paired t-test, and the association between cytokine values and clinical outcome scores was performed with Pearson's correlation coefficient with an alpha value of 0.05 set as significant. Sixteen of seventeen patients completed 2-year follow-up questionnaires (94%). There was a significant increase in pre-operative to post-operative score for each clinical outcome measure. No statistically significant correlation was seen between any of the intra-operative cytokine values and either the 2-year follow-up scores or the change from pre-operative to final follow-up outcome values. No statistically significant associations were seen between hip synovial fluid cytokine concentrations and 2-year follow-up clinical outcome assessment scores for those undergoing hip arthroscopy.

    View details for DOI 10.1093/jhps/hnw013

    View details for PubMedID 27583163

  • Acetabular Dysplasia and Surgical Approaches Other Than Direct Anterior Increases Risk for Malpositioning of the Acetabular Component in Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Gromov, K., Greene, M. E., Huddleston, J. I., Emerson, R., Gebuhr, P., Malchau, H., Troelsen, A. 2016; 31 (4): 835-841


    Persistent acetabular dysplasia (AD) after periacetabular osteotomy has been hypothesized to increase the risk for malpositioning of the acetabular component. In this study, we investigate whether AD is an independent risk factor for cup malpositioning during primary total hip arthroplasty (THA).Patient demographics, surgical approach, presence of AD assessed using the lateral center-edge angle, and acetabular cup positioning determined using Martell Hip Analysis Suite were investigated in 836 primary THA patients enrolled in a prospective multicenter study.We found that presence of AD, defined as the lateral center-edge angle of <25°, is an independent risk factor for malpositioning of the acetabular component during primary THA. Surgical approach other than direct anterior was also independently associated with malpositioned cups.Surgeons should therefore take special care during placement of the acetabular component in patients with AD.

    View details for DOI 10.1016/j.arth.2015.10.045

    View details for Web of Science ID 000373625600018

    View details for PubMedID 26706838

  • Removal of Well-Fixed Cementless Acetabular Components in Revision Total Hip Arthroplasty. Orthopedics Adelani, M. A., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2016; 39 (2): e280-4


    The Zimmer Explant Acetabular Cup Removal System (Warsaw, Indiana) has been touted as a superior method for removing well-fixed cementless acetabular components while minimizing bone loss; however, no comparative data support this. This study compares bone loss following the removal of well-fixed acetabular components with Aufranc gouges and with the Explant System. A review of 623 revision total hip arthroplasties (THAs) at the authors' institution between 2002 and 2013 identified cases involving the revision of well-fixed cementless hemispherical acetabular components for any reason except infection. Twenty-four cases using Aufranc gouges and 27 cases using the Explant System were included. The following surrogates for bone loss were used: (1) the difference between the initial acetabular component outer diameter (OD) and the final reamer OD; (2) the difference between the initial acetabular component OD and the new acetabular component OD; and (3) the use of impaction bone grafting. A 2-tailed Wilcoxon-Mann-Whitney test was used to assess the difference in bone loss between the 2 groups. The use of bone grafting was compared between the groups with the chi-square test. The median differences between the initial acetabular component and the final reamer (P=.004), as well as between the initial and new acetabular components (P=.002), were 2 mm less with the Explant System. Hips in the Aufranc group were more likely to have bone grafting (54% vs 26%; P=.04). These results suggest less bone loss when removing well-fixed acetabular components with the Zimmer Explant System compared with Aufranc gouges. [Orthopedics. 2016; 39(2):e280-e284.].

    View details for DOI 10.3928/01477447-20160129-04

    View details for PubMedID 26840697

  • 3-year follow-up of a long-term registry-based multicentre study on vitamin E diffused polyethylene in total hip replacement. Hip international Sillesen, N. H., Greene, M. E., Nebergall, A. K., Huddleston, J. I., Emerson, R., Gebuhr, P., Troelsen, A., Malchau, H. 2016; 26 (1): 97-103


    Preclinical studies of vitamin E diffused highly cross-linked polyethylene (E-XLPE) has shown enhanced mechanical properties with less wear. The purpose of our study was to document the early clinical outcome of E-XLPE to ensure, for the safety of patients, that there are no unforeseen early adverse events from using this new biomaterial.The enrolled patients (n = 977) have received either a porous titanium coated or porous plasma sprayed acetabular shell with either a E-XLPE liner or a medium cross-linked (AXL) liner. At each follow-up 5 patient-reported outcome measures (PROMs) were completed: Harris Hip Score, Case Mix Indicator, UCLA Activity Score, SF-36, and EQ-5D. Radiographs were measured for cup and stem position, as well as femoral head penetration into the liner (wear). Postoperative complications and revisions were collected.At 3 years follow-up, there were 13 revisions due to: 4 periprosthetic fractures; 1 sepsis; 6 instabilities; and 2 implant mismatches at surgery. Wear of the hip implant, calculated by software analysis of pelvis x-rays, from the postoperative interval to 3 years showed a liner penetration rate of 0.027 mm/year for AXL and 0.005 mm/year for E-XLPE with no significant difference between the 2 (p = 0.24). Improvement was seen in all PROMs from the preoperative interval to 3 years after surgery (p<0.0001).Early follow-up of the E-XLPE and AXL liners show low penetration. PROMs indicate improvement after total hip arthroplasty in functionality and quality of life across the centers. We have not observed any early in vivo adverse effects from diffusing the liners with vitamin Identifier: NCT00545285.

    View details for DOI 10.5301/hipint.5000297

    View details for PubMedID 26692248

  • Is There a Benefit to Modularity in 'Simpler' Femoral Revisions? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Huddleston, J. I., Tetreault, M. W., Yu, M., Bedair, H., Hansen, V. J., Choi, H., Goodman, S. B., Sporer, S. M., Della Valle, C. J. 2016; 474 (2): 415-420
  • Treatment of Periprosthetic Knee Infection With a Two-stage Protocol Using Static Spacers CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Lichstein, P., Su, S., Hedlund, H., Suh, G., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2016; 474 (1): 120-125
  • 3-year follow-up of a long-term registry-based multicentre study on vitamin E diffused polyethylene in total hip replacement HIP INTERNATIONAL Sillesen, N. H., Greene, M. E., Nebergall, A. K., Huddleston, J. I., Emerson, R., Gebuhr, P., Troelsen, A., Malchau, H. 2016; 26 (1): 97-103
  • Predictors of Low Patient-Reported Outcomes Response Rates in the California Joint Replacement Registry JOURNAL OF ARTHROPLASTY Patel, J., Lee, J. H., Li, Z., SooHoo, N. F., Bozic, K., Huddleston, J. I. 2015; 30 (12): 2071-2075
  • A global reference for human genetic variation NATURE Altshuler, D. M., Durbin, R. M., Abecasis, G. R., Bentley, D. R., Chakravarti, A., Clark, A. G., Donnelly, P., Eichler, E. E., Flicek, P., Gabriel, S. B., Gibbs, R. A., Green, E. D., Hurles, M. E., Knoppers, B. M., Korbel, J. O., Lander, E. S., Lee, C., Lehrach, H., Mardis, E. R., Marth, G. T., McVean, G. A., Nickerson, D. A., Schmidt, J. P., Sherry, S. T., Wang, J., Wilson, R. K., Gibbs, R. A., Boerwinkle, E., Doddapaneni, H., Han, Y., Korchina, V., Kovar, C., Lee, S., Muzny, D., Reid, J. G., Zhu, Y., Wang, J., Chang, Y., Feng, Q., Fang, X., Guo, X., Jian, M., Jiang, H., Jin, X., Lan, T., Li, G., Li, J., Li, Y., Liu, S., Liu, X., Lu, Y., Ma, X., Tang, M., Wang, B., Wang, G., Wu, H., Wu, R., Xu, X., Yin, Y., Zhang, D., Zhang, W., Zhao, J., Zhao, M., Zheng, X., Lander, E. S., Altshuler, D. M., Gabriel, S. B., Gupta, N., Gharani, N., Toji, L. H., Gerry, N. P., Resch, A. M., Flicek, P., Barker, J., Clarke, L., Gil, L., Hunt, S. E., Kelman, G., Kulesha, E., Leinonen, R., McLaren, W. M., Radhakrishnan, R., Roa, A., Smirnov, D., Smith, R. E., Streeter, I., Thormann, A., Toneva, I., Vaughan, B., Zheng-Bradley, X., Bentley, D. R., Grocock, R., Humphray, S., James, T., Kingsbury, Z., Lehrach, H., Sudbrak, R., Albrecht, M. W., Amstislavskiy, V. S., Borodina, T. A., Lienhard, M., Mertes, F., Sultan, M., Timmermann, B., Yaspo, M., Mardis, E. R., Wilson, R. K., Fulton, L., Fulton, R., Sherry, S. T., Ananiev, V., Belaia, Z., Beloslyudtsev, D., Bouk, N., Chen, C., Church, D., Cohen, R., Cook, C., Garner, J., Hefferon, T., Kimelman, M., Liu, C., Lopez, J., Meric, P., O'Sullivan, C., Ostapchuk, Y., Phan, L., Ponomarov, S., Schneider, V., Shekhtman, E., Sirotkin, K., Slotta, D., Zhang, H., McVean, G. A., Durbin, R. M., Balasubramaniam, S., Burton, J., Danecek, P., Keane, T. M., Kolb-Kokocinski, A., McCarthy, S., Stalker, J., Quail, M., Schmidt, J. P., Davies, C. J., Gollub, J., Webster, T., Wong, B., Zhan, Y., Auton, A., Campbell, C. L., Kong, Y., Marcketta, A., Gibbs, R. A., Yu, F., Antunes, L., Bainbridge, M., Muzny, D., Sabo, A., Huang, Z., Wang, J., Coin, L. J., Fang, L., Guo, X., Jin, X., Li, G., Li, Q., Li, Y., Li, Z., Lin, H., Liu, B., Luo, R., Shao, H., Xie, Y., Ye, C., Yu, C., Zhang, F., Zheng, H., Zhu, H., Alkan, C., Dal, E., Kahveci, F., Marth, G. T., Garrison, E. P., Kural, D., Lee, W., Leong, W. F., Stromberg, M., Ward, A. N., Wu, J., Zhang, M., Daly, M. J., DePristo, M. A., Handsaker, R. E., Altshuler, D. M., Banks, E., Bhatia, G., del Angel, G., Gabriel, S. B., Genovese, G., Gupta, N., Li, H., Kashin, S., Lander, E. S., McCarroll, S. A., Nemesh, J. C., Poplin, R. E., Yoon, S. C., Lihm, J., Makarov, V., Clark, A. G., Gottipati, S., Keinan, A., Rodriguez-Flores, J. L., Korbel, J. O., Rausch, T., Fritz, M. H., Stuetz, A. M., Flicek, P., Beal, K., Clarke, L., Datta, A., Herrero, J., McLaren, W. M., Ritchie, G. R., Smith, R. E., Zerbino, D., Zheng-Bradley, X., Sabeti, P. C., Shlyakhter, I., Schaffner, S. F., Vitti, J., Cooper, D. N., Ball, E. V., Stenson, P. D., Bentley, D. R., Barnes, B., Bauer, M., Cheetham, R. K., Cox, A., Eberle, M., Humphray, S., Kahn, S., Murray, L., Peden, J., Shaw, R., Kenny, E. E., Batzer, M. A., Konkel, M. K., Walker, J. A., MacArthur, D. G., Lek, M., Sudbrak, R., Amstislavskiy, V. S., Herwig, R., Mardis, E. R., Ding, L., Koboldt, D. C., Larson, D., Ye, K., Gravel, S., Swaroop, A., Chew, E., Lappalainen, T., Erlich, Y., Gymrek, M., Willems, T. F., Simpson, J. T., Shriver, M. D., Rosenfeld, J. A., Bustamante, C. D., Montgomery, S. B., De La Vega, F. M., Byrnes, J. K., Carroll, A. W., DeGorter, M. K., Lacroute, P., Maples, B. K., Martin, A. R., Moreno-Estrada, A., Shringarpure, S. S., Zakharia, F., Halperin, E., Baran, Y., Lee, C., Cerveira, E., Hwang, J., Malhotra, A., Plewczynski, D., Radew, K., Romanovitch, M., Zhang, C., Hyland, F. C., Craig, D. W., Christoforides, A., Homer, N., Izatt, T., Kurdoglu, A. A., Sinari, S. A., Squire, K., Sherry, S. T., Xiao, C., Sebat, J., Antaki, D., Gujral, M., Noor, A., Ye, K., Burchard, E. G., Hernandez, R. D., Gignoux, C. R., Haussler, D., Katzman, S. J., Kent, W. J., Howie, B., Ruiz-Linares, A., Dermitzakis, E. T., Devine, S. E., Goncalo, R. A., Kang, H. M., Kidd, J. M., Blackwell, T., Caron, S., Chen, W., Emery, S., Fritsche, L., Fuchsberger, C., Jun, G., Li, B., Lyons, R., Scheller, C., Sidore, C., Song, S., Sliwerska, E., Taliun, D., Tan, A., Welch, R., Wing, M. K., Zhan, X., Awadalla, P., Hodgkinson, A., Li, Y., Shi, X., Quitadamo, A., Lunter, G., McVean, G. A., Marchini, J. L., Myers, S., Churchhouse, C., Delaneau, O., Gupta-Hinch, A., Kretzschmar, W., Iqbal, Z., Mathieson, I., Menelaou, A., Rimmer, A., Xifara, D. K., Oleksyk, T. K., Fu, Y., Liu, X., Xiong, M., Jorde, L., Witherspoon, D., Xing, J., Eichler, E. E., Browning, B. L., Browning, S. R., Hormozdiari, F., Sudmant, P. H., Khurana, E., Durbin, R. M., Hurles, M. E., Tyler-Smith, C., Albers, C. A., Ayub, Q., Balasubramaniam, S., Chen, Y., Colonna, V., Danecek, P., Jostins, L., Keane, T. M., McCarthy, S., Walter, K., Xue, Y., Gerstein, M. B., Abyzov, A., Balasubramanian, S., Chen, J., Clarke, D., Fu, Y., Harmanci, A. O., Jin, M., Lee, D., Liu, J., Mu, X. J., Zhang, J., Zhang, Y., Li, Y., Luo, R., Zhu, H., Alkan, C., Dal, E., Kahveci, F., Marth, G. T., Garrison, E. P., Kural, D., Lee, W., Ward, A. N., Wu, J., Zhang, M., McCarroll, S. A., Handsaker, R. E., Altshuler, D. M., Banks, E., del Angel, G., Genovese, G., Hartl, C., Li, H., Kashin, S., Nemesh, J. C., Shakir, K., Yoon, S. C., Lihm, J., Makarov, V., Degenhardt, J., Korbel, J. O., Fritz, M. H., Meiers, S., Raeder, B., Rausch, T., Stuetz, A. M., Flicek, P., Casale, F. P., Clarke, L., Smith, R. E., Stegle, O., Zheng-Bradley, X., Bentley, D. R., Barnes, B., Cheetham, R. K., Eberle, M., Humphray, S., Kahn, S., Murray, L., Shaw, R., Lameijer, E., Batzer, M. A., Konkel, M. K., Walker, J. A., Ding, L., Hall, I., Ye, K., Lacroute, P., Lee, C., Cerveira, E., Malhotra, A., Hwang, J., Plewczynski, D., Radew, K., Romanovitch, M., Zhang, C., Craig, D. W., Homer, N., Church, D., Xiao, C., Sebat, J., Antaki, D., Bafna, V., Michaelson, J., Ye, K., Devine, S. E., Gardner, E. J., Abecasis, G. R., Kidd, J. M., Mills, R. E., Dayama, G., Emery, S., Jun, G., Shi, X., Quitadamo, A., Lunter, G., McVean, G. A., Chen, K., Fan, X., Chong, Z., Chen, T., Witherspoon, D., Xing, J., Eichler, E. E., Chaisson, M. J., Hormozdiari, F., Huddleston, J., Malig, M., Nelson, B. J., Sudmant, P. H., Parrish, N. F., Khurana, E., Hurles, M. E., Blackburne, B., Lindsay, S. J., Ning, Z., Walter, K., Zhang, Y., Gerstein, M. B., Abyzov, A., Chen, J., Clarke, D., Lam, H., Mu, X. J., Sisu, C., Zhang, J., Zhang, Y., Gibbs, R. A., Yu, F., Bainbridge, M., Challis, D., Evani, U. S., Kovar, C., Lu, J., Muzny, D., Nagaswamy, U., Reid, J. G., Sabo, A., Yu, J., Guo, X., Li, W., Li, Y., Wu, R., Marth, G. T., Garrison, E. P., Leong, W. F., Ward, A. N., del Angel, G., DePristo, M. A., Gabriel, S. B., Gupta, N., Hartl, C., Poplin, R. E., Clark, A. G., Rodriguez-Flores, J. L., Flicek, P., Clarke, L., Smith, R. E., Zheng-Bradley, X., MacArthur, D. G., Mardis, E. R., Fulton, R., Koboldt, D. C., Gravel, S., Bustamante, C. D., Craig, D. W., Christoforides, A., Homer, N., Izatt, T., Sherry, S. T., Xiao, C., Dermitzakis, E. T., Abecasis, G. R., Kang, H. M., McVean, G. A., Gerstein, M. B., Balasubramanian, S., Habegger, L., Yu, H., Flicek, P., Clarke, L., Cunningham, F., Dunham, I., Zerbino, D., Zheng-Bradley, X., Lage, K., Jespersen, J. B., Horn, H., Montgomery, S. B., DeGorter, M. K., Khurana, E., Tyler-Smith, C., Chen, Y., Colonna, V., Xue, Y., Gerstein, M. B., Balasubramanian, S., Fu, Y., Kim, D., Auton, A., Marcketta, A., DeSalle, R., Narechania, A., Sayres, M. A., Garrison, E. P., Handsaker, R. E., Kashin, S., McCarroll, S. A., Rodriguez-Flores, J. L., Flicek, P., Clarke, L., Zheng-Bradley, X., Erlich, Y., Gymrek, M., Willems, T. F., Bustamante, C. D., Mendez, F. L., Poznik, G. D., Underhill, P. A., Lee, C., Cerveira, E., Malhotra, A., Romanovitch, M., Zhang, C., Abecasis, G. R., Coin, L., Shao, H., Mittelman, D., Tyler-Smith, C., Ayub, Q., Banerjee, R., Cerezo, M., Chen, Y., Fitzgerald, T., Louzada, S., Massaia, A., McCarthy, S., Ritchie, G. R., Xue, Y., Yang, F., Gibbs, R. A., Kovar, C., Kalra, D., Hale, W., Muzny, D., Reid, J. G., Wang, J., Dan, X., Guo, X., Li, G., Li, Y., Ye, C., Zheng, X., Altshuler, D. M., Flicek, P., Clarke, L., Zheng-Bradley, X., Bentley, D. R., Cox, A., Humphray, S., Kahn, S., Sudbrak, R., Albrecht, M. W., Lienhard, M., Larson, D., Craig, D. W., Izatt, T., Kurdoglu, A. A., Sherry, S. T., Xiao, C., Haussler, D., Abecasis, G. R., McVean, G. A., Durbin, R. M., Balasubramaniam, S., Keane, T. M., McCarthy, S., Stalker, J., Chakravarti, A., Knoppers, B. M., Abecasis, G. R., Barnes, K. C., Beiswanger, C., Burchard, E. G., Bustamante, C. D., Cai, H., Cao, H., Durbin, R. M., Gerry, N. P., Gharani, N., Gibbs, R. A., Gignoux, C. R., Gravel, S., Henn, B., Jones, D., Jorde, L., Kaye, J. S., Keinan, A., Kent, A., Kerasidou, A., Li, Y., Mathias, R., McVean, G. A., Moreno-Estrada, A., Ossorio, P. N., Parker, M., Resch, A. M., Rotimi, C. N., Royal, C. D., Sandoval, K., Su, Y., Sudbrak, R., Tian, Z., Tishkoff, S., Toji, L. H., Tyler-Smith, C., Via, M., Wang, Y., Yang, H., Yang, L., Zhu, J., Bodmer, W., Bedoya, G., Ruiz-Linares, A., Cai, Z., Gao, Y., Chu, J., Peltonen, L., Garcia-Montero, A., Orfao, A., Dutil, J., Martinez-Cruzado, J. C., Oleksyk, T. K., Barnes, K. C., Mathias, R. A., Hennis, A., Watson, H., McKenzie, C., Qadri, F., LaRocque, R., Sabeti, P. C., Zhu, J., Deng, X., Sabeti, P. C., Asogun, D., Folarin, O., Happi, C., Omoniwa, O., Stremlau, M., Tariyal, R., Jallow, M., Joof, F. S., Corrah, T., Rockett, K., Kwiatkowski, D., Kooner, J., Tran Tinh Hien, T. T., Dunstan, S. J., Nguyen Thuy Hang, N. T., Fonnie, R., Garry, R., Kanneh, L., Moses, L., Sabeti, P. C., Schieffelin, J., Grant, D. S., Gallo, C., Poletti, G., Saleheen, D., Rasheed, A., Brook, L. D., Felsenfeld, A., McEwen, J. E., Vaydylevich, Y., Green, E. D., Duncanson, A., Dunn, M., Schloss, J. A., Wang, J., Yang, H., Auton, A., Brooks, L. D., Durbin, R. M., Garrison, E. P., Kang, H. M., Korbel, J. O., Marchini, J. L., McCarthy, S., McVean, G. A., Abecasis, G. R. 2015; 526 (7571): 68-?
  • Does Intraoperative Fluoroscopy Optimize Limb Length and the Precision of Acetabular Positioning in Primary THA? ORTHOPEDICS Leucht, P., Huddleston, H. G., Bellino, M. J., Huddleston, J. I. 2015; 38 (5): E380-E386


    Reduced limb length discrepancy and more accurate cup positioning are purported benefits of using fluoroscopy for total hip arthroplasty (THA). The authors compared limb length discrepancy and cup position in 200 patients (group I, posterior approach without fluoroscopy; group II, anterior supine approach with fluoroscopy) who underwent primary THA. Mean limb length discrepancy was 2.7 mm (SD, 5.2 mm; range, -9.8 to 20.9 mm) and 0.7 mm (SD, 3.7 mm; range, -11.8 to 10.5 mm) for groups I and II, respectively (P=.002). In group I, 7% of hips had limb length discrepancy greater than 1 cm compared with 3% in group II. Mean cup inclination measured 40.8° (SD, 5.0°; range, 26.1°-53.7°) in group I and 43.4° (SD, 5.6°; range, 31.3°-55.9°) in group II (P=.008). In group I, 96% of cups had inclination within 10° of the mean compared with 92% in group II (P=.24). Mean anteversion measured 35.3° (SD, 7.1°; range, 17.8°-60.7°) in group I and 25.9° (SD, 8.2°; range, 1.5°-44.8°) in group II (P=.0001). In group I, 87% of hips exhibited anteversion within 10° of the mean compared with 76% in group II (P=.045). Although the anterior approach with intraoperative fluoroscopy reduced mean limb length discrepancy, the clinical significance of this reduction is unclear. Fluoroscopy reduced the incidence of limb length discrepancy greater than 1 cm. However, the use of fluoroscopy did not help to improve the precision of cup positioning.

    View details for DOI 10.3928/01477447-20150504-54

    View details for Web of Science ID 000356148900005

    View details for PubMedID 25970364

  • Collecting Patient-Reported Outcomes: Lessons from the California Joint Replacement Registry. EGEMS (Washington, DC) Chenok, K., Teleki, S., SooHoo, N. F., Huddleston, J., Bozic, K. J. 2015; 3 (1): 1196-?


    While patient-reported outcomes (PROs) have long been used for research, recent technology advancements make it easier to collect patient feedback and use it for patient care. Despite the promise and appeal of PROs, substantial barriers to widespread adoption remain-including challenges in interpreting privacy regulations, educating patients and physicians about the power that PRO collection can provide to patient-centered care.This article describes lessons learned from the California Joint Replacement Registry's (CJRR) five-year effort to collect PROs from patients undergoing total hip and total knee replacement surgeries. CJRR is a voluntary, multi-institutional registry in California that collects clinical and device information, as well as PROs from patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries.The CJRR encountered and developed solutions to overcome several key issues: (1) limitations of electronic PRO collection, (2) challenges in patient recruitment and tracking, (3) challenges in encouraging patients to complete PRO surveys, (4) real and perceived administrative burden to clinic and hospital staff, (5) surgeon engagement, and (6) survey costs.The CJRR's field experience can inform growing numbers of providers and researchers who seek to more fully understand the impact of care from the patient's perspective. In addition, the authors believe that these challenges can best be addressed through a combination of policy changes and increased incentives.

    View details for DOI 10.13063/2327-9214.1196

    View details for PubMedID 26793737

  • Total knee arthroplasty in patients with ipsilateral fused hip: a technical note. Clinics in orthopedic surgery Goodman, S. B., Huddleston, J. I., Hur, D., Song, S. J. 2014; 6 (4): 476-479


    We report the surgical technique used to perform posterior-stabilized total knee arthroplasty (TKA) in two patients with a well positioned and functional hip arthrodesis. Intraoperatively, the operating table was placed in an increased Trendelenburg position. Episodically, we flexed the foot of the table by 90° to allow maximal knee flexion to facilitate exposure and bone cuts. We opted to resect the patella and tibia first to enable exposure, given the stiffness of the arthritic knee. One patient's medical condition prohibited complex conversion total hip arthroplasty (THA) prior to the TKA. The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky. The final outcome provided satisfactory results at a minimum of 2 years postoperatively. TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

    View details for DOI 10.4055/cios.2014.6.4.476

    View details for PubMedID 25436074

  • Regional Differences Between US and Europe in Radiological Osteoarthritis and Self Assessed Quality of Life in Patients Undergoing Total Hip Arthroplasty Surgery JOURNAL OF ARTHROPLASTY Gromov, K., Greene, M. E., Sillesen, N. H., Troelsen, A., Malchau, H., Huddleston, J. I., Emerson, R., Garcia-Cimbrelo, E., Gebuhr, P. 2014; 29 (11): 2078-2083
  • Clinical recovery from surgery correlates with single-cell immune signatures SCIENCE TRANSLATIONAL MEDICINE Gaudilliere, B., Fragiadakis, G. K., Bruggner, R. V., Nicolau, M., Finck, R., Tingle, M., Silva, J., Ganio, E. A., Yeh, C. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Davis, M. M., Bendall, S. C., Fantl, W. J., Angst, M. S., Nolan, G. P. 2014; 6 (255)
  • Clinical recovery from surgery correlates with single-cell immune signatures. Science translational medicine Gaudillière, B., Fragiadakis, G. K., Bruggner, R. V., Nicolau, M., Finck, R., Tingle, M., Silva, J., Ganio, E. A., Yeh, C. G., Maloney, W. J., Huddleston, J. I., Goodman, S. B., Davis, M. M., Bendall, S. C., Fantl, W. J., Angst, M. S., Nolan, G. P. 2014; 6 (255): 255ra131-?


    Delayed recovery from surgery causes personal suffering and substantial societal and economic costs. Whether immune mechanisms determine recovery after surgical trauma remains ill-defined. Single-cell mass cytometry was applied to serial whole-blood samples from 32 patients undergoing hip replacement to comprehensively characterize the phenotypic and functional immune response to surgical trauma. The simultaneous analysis of 14,000 phosphorylation events in precisely phenotyped immune cell subsets revealed uniform signaling responses among patients, demarcating a surgical immune signature. When regressed against clinical parameters of surgical recovery, including functional impairment and pain, strong correlations were found with STAT3 (signal transducer and activator of transcription), CREB (adenosine 3',5'-monophosphate response element-binding protein), and NF-κB (nuclear factor κB) signaling responses in subsets of CD14(+) monocytes (R = 0.7 to 0.8, false discovery rate <0.01). These sentinel results demonstrate the capacity of mass cytometry to survey the human immune system in a relevant clinical context. The mechanistically derived immune correlates point to diagnostic signatures, and potential therapeutic targets, that could postoperatively improve patient recovery.

    View details for DOI 10.1126/scitranslmed.3009701

    View details for PubMedID 25253674

  • Registries collecting level-I through IV Data: institutional and multicenter use: AAOS exhibit selection. journal of bone and joint surgery. American volume Hansen, V. J., Greene, M. E., Bragdon, M. A., Nebergall, A. K., Barr, C. J., Huddleston, J. I., Bragdon, C. R., Malchau, H. 2014; 96 (18)

    View details for DOI 10.2106/JBJS.M.01458

    View details for PubMedID 25232090

  • Patient, surgeon, and healthcare purchaser views on the use of decision and communication aids in orthopaedic surgery: a mixed methods study BMC HEALTH SERVICES RESEARCH Bozic, K. J., Chenok, K. E., Schindel, J., Chan, V., Huddleston, J. I., Braddock, C., Belkora, J. 2014; 14
  • Current Modes of Failure in TKA: Infection, Instability, and Stiffness Predominate CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Le, D. H., Goodman, S. B., Maloney, W. J., Huddleston, J. I. 2014; 472 (7): 2197-2200


    Historically, polyethylene wear and its sequelae (osteolysis, late instability, aseptic loosening) were common causes for revision total knee arthroplasty (TKA). Recently, polyethylene manufacturing has become more consistent; furthermore, a clearer understanding of the importance of oxidation on polyethylene performance led to packaging of the polyethylene bearings in an inert environment. This improved the quality and consistency of polyethylene used in TKA, raising the question of whether different failure modes now predominate after TKA.The purpose of this study was to determine the current reasons for (1) early and (2) late failures after TKA at one high-volume arthroplasty center.We reviewed all first-time revision TKAs performed between 2001 and 2011 at one institution, yielding a group of 253 revision TKAs in 251 patients. Mean age at the time of revision was 64 years (SD 10 years). Mean time to revision was 35 months (SD 23 months). Preoperative evaluations, laboratory data, radiographs, and intraoperative findings were used to determine causes for revision. Early failure was defined as revision within 2 years of the index procedure. The primary failure mechanism was determined by the operating surgeon.Early failure accounted for 46% (116 of 253) of all revisions with infection (28 of 116 [24%]), instability (30 of 116 [26%]), and stiffness (21 of 116 [18%]) being the leading causes. Late failure accounted for 54% (137 of 253) of all revisions with the most common causes including infection (34 of 137 [25%]), instability (24 of 137 [18%]), and stiffness (19 of 253 [14%]). Polyethylene wear was implicated as the failure mechanism in 2% of early cases (two of 116) and 9% of late cases (13 of 137).In contrast to previous studies, wear-related implant failure in TKA was relatively uncommon in this series. Changes in polyethylene manufacturing, sterilization, and storage may have accounted for some of this difference; however, longer-term followup will be required to verify this finding. Infection, instability, and stiffness represent the most common causes of early and late failure. Strategies to improve outcomes in TKA should be aimed at infection prophylaxis and treatment, surgical technique, and patient selection.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1007/s11999-014-3540-y

    View details for Web of Science ID 000337021300031

    View details for PubMedID 24615421

  • Polyethylene Wear and Osteolysis Is Associated With High Revision Rate of a Small Sized Porous Coated THA in Patients With Hip Dysplasia JOURNAL OF ARTHROPLASTY Murray, P. J., Hwang, K. L., Imrie, S. N., Huddleston, J. I., Goodman, S. B. 2014; 29 (7): 1373-1377


    The outcome of 25 primary THAs in patients with hip dysplasia using the AML Bantam femoral stem (DePuy) is reported. Age at operation averaged 43 ± 10 years. Twenty-two of 25 stems were cementless. All cementless acetabular components had conventional or cross-linked polyethylene and screws. Follow-up averaged 11 ± 5 years (range 4-18). Four cementless stems were revised after 3, 4, 8, and 9 years; 2/3 cemented stems were revised at 8 and 18 years. Femoral revisions demonstrated extensive conventional polyethylene wear, periprosthetic osteolysis and loosening. Five entire cups were revised for wear and loosening; four liners were replaced. Harris Hip Scores for patients with retained stems went from 43 ± 12 to 85 ± 13. High revision rates with the proximally porous coated Bantam stem are due to loss of fixation, often associated with polyethylene wear and osteolysis.

    View details for DOI 10.1016/j.arth.2014.02.027

    View details for Web of Science ID 000338941600010

  • Outcome of Porous Tantalum Acetabular Components for Paprosky Type 3 and 4 Acetabular Defects JOURNAL OF ARTHROPLASTY Batuyong, E. D., Brock, H. S., Thiruvengadam, N., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2014; 29 (6): 1318-1322


    Porous tantalum acetabular implants provide a potential solution for dealing with significant acetabular bone loss. This study reviews 24 acetabular revisions using tantalum implants for Paprosky type 3 and 4 defects. The mean Harris Hip Score improved from 35±19 (range, 4-71) to 88±14 (range, 41-100), p<0.0001. Postoperative radiographs showed radiolucent lines in 14 hips with a mean width of 1.3±1.0mm (range, 0.27-4.37mm). No gaps enlarged and 71% of them disappeared at a mean of 13±10months (range, 3-29months). At a mean follow-up of 37±14months (range, 24-66months), 22 reconstructions showed radiograpic evidence of osseointegration (92%). The two failures were secondary to septic loosening. When dealing with severe acetabular bone loss, porous tantalum acetabular components show promising short-term results.

    View details for DOI 10.1016/j.arth.2013.12.002

    View details for Web of Science ID 000338115400048

    View details for PubMedID 24405625

  • Fibronectin-aggrecan complex as a marker for cartilage degradation in non-arthritic hips KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Abrams, G. D., Safran, M. R., Shapiro, L. M., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Bellino, M. J., Scuderi, G. J. 2014; 22 (4): 768-773


    To report hip synovial fluid cytokine concentrations in hips with and without radiographic arthritis.Patients with no arthritis (Tonnis grade 0) and patients with Tonnis grade 2 or greater hip osteoarthritis (OA) were identified from patients undergoing either hip arthroscopy or arthroplasty. Synovial fluid was collected at the time of portal establishment for those undergoing hip arthroscopy and prior to arthrotomy for the arthroplasty group. Analytes included fibronectin-aggrecan complex (FAC) as well as a standard 12 cytokine array. Variables recorded were Tonnis grade, centre-edge angle of Wiberg, as well as labrum and cartilage pathology for the hip arthroscopy cohort. A priori power analysis was conducted, and a Mann-Whitney U test and regression analyses were used with an alpha value of 0.05 set as significant.Thirty-four patients were included (17 arthroplasty, 17 arthroscopy). FAC was the only analyte to show a significant difference between those with and without OA (p < 0.001). FAC had significantly higher concentration in those without radiographic evidence of OA undergoing microfracture versus those not receiving microfracture (p < 0.05).There was a significantly higher FAC concentration in patients without radiographic OA. Additionally, those undergoing microfracture had increased levels of FAC. As FAC is a cartilage breakdown product, no significant amounts may be present in those with OA. In contrast, those undergoing microfracture have focal area(s) of cartilage breakdown. These data suggest that FAC may be useful in predicting cartilage pathology in those patients with hip pain but without radiographic evidence of arthritis.Diagnostic, Level III.

    View details for DOI 10.1007/s00167-014-2863-2

    View details for Web of Science ID 000333157000010

  • Causes of Instability After Total Knee Arthroplasty JOURNAL OF ARTHROPLASTY Song, S. J., Detch, R. C., Maloney, W. J., Goodman, S. B., Huddleston, J. I. 2014; 29 (2): 360-364


    The purpose of the present study was to characterize the underlying causes that lead to instability after total knee arthroplasty (TKA). We reviewed 83 revision TKAs (79 patients) performed for instability. After detailed analysis of patient's history, physical examination, operative report and radiographs, we identified six categories: flexion/extension gap mismatch, component malposition, isolated ligament insufficiency, extensor mechanism insufficiency, component loosening, and global instability. Twenty-five knees presented with multi-factorial instability. When these knees were classified according to the most fundamental category, each category above included 24, 12, 11, 10, 10 and 16 knees respectively. The unstable TKA may result from a variety of distinct etiologies which must be identified and treated at the time of revision. The revision TKA could be tailored to the specific causes.

    View details for DOI 10.1016/j.arth.2013.06.023

    View details for Web of Science ID 000331345600022

  • Fractography and oxidative analysis of gamma inert sterilized posterior-stabilized tibial insert post fractures: Report of two cases KNEE Ansari, F., Chang, J., Huddleston, J., Van Citters, D., Ries, M., Pruitt, L. 2013; 20 (6): 609-613


    Highly crosslinked ultra-high molecular weight polyethylene (UHMWPE) has shown success in reducing wear in hip arthroplasty but there remains skepticism about its use in Total Knee Replacement (TKR) inserts that are known to experience fatigue loading and higher local cyclic contact stresses.Two Legacy Posterior-Stabilized (LPS) Zimmer NexGen tibial implants sterilized by gamma irradiation in an inert environment with posts that fractured in vivo were analyzed. Failure mechanisms were determined using optical and scanning electron microscopy along with oxidative analysis via Fourier Transform Infra-Red (FTIR) spectroscopy.Micrographs of one retrieval revealed fatigue crack initiation on opposite sides of the post and quasi-brittle micromechanisms of crack propagation. FTIR of this retrieval revealed no oxidation. The fracture surface image of the second retrieval indicated a brittle fracture process and FTIR revealed oxidation in the explant.These two cases suggest that crosslinking of UHMWPE as a manufacturing process or sterilization method in conjunction with designs that incorporate high stress concentrations, such as the tibial post, may reduce material strength. Moreover, free radicals generated from ionizing radiation can render the polymer susceptible to oxidative embrittlement.Our findings suggest that tibial post fractures may be the results of in vivo oxidation and low level crosslinking. These and previous reports of fractured crosslinked UHMWPE devices implores caution when used with high stress concentrations, particularly when considering the potential for in vivo oxidation in TKR.

    View details for DOI 10.1016/j.knee.2013.04.004

    View details for Web of Science ID 000330824200046

    View details for PubMedID 24220187

  • Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. journal of bone and joint surgery. American volume Bozic, K. J., Belkora, J., Chan, V., Youm, J., Zhou, T., Dupaix, J., Bye, A. N., Braddock, C. H., Chenok, K. E., Huddleston, J. I. 2013; 95 (18): 1633-1639


    Despite evidence that shared decision-making tools for treatment decisions improve decision quality and patient engagement, they are not commonly employed in orthopaedic practice. The purpose of this study was to evaluate the impact of decision and communication aids on patient knowledge, efficiency of decision making, treatment choice, and patient and surgeon experience in patients with osteoarthritis of the hip or knee.One hundred and twenty-three patients who were considered medically appropriate for hip or knee replacement were randomized to either a shared decision-making intervention or usual care. Patients in the intervention group received a digital video disc and booklet describing the natural history and treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach. Patients in the control group received information about the surgeon's practice. Both groups reported their knowledge and stage in decision making and their treatment choice, satisfaction, and communication with their surgeon. Surgeons reported the appropriateness of patient questions and their satisfaction with the visit. The primary outcome measure tracked whether patients reached an informed decision during their first visit. Statistical analyses were performed to evaluate differences between groups.Significantly more patients in the intervention group (58%) reached an informed decision during the first visit compared with the control group (33%) (p = 0.005). The intervention group reported higher confidence in knowing what questions to ask their doctor (p = 0.0034). After the appointment, there was no significant difference between groups in the percentage of patients choosing surgery (p = 0.48). Surgeons rated the number and appropriateness of patient questions higher in the intervention group (p < 0.0001), reported higher satisfaction with the efficiency of the intervention group visits (p < 0.0001), and were more satisfied overall with the intervention group visits (p < 0.0001).Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice.

    View details for DOI 10.2106/JBJS.M.00004

    View details for PubMedID 24048550

  • Shared Decision Making in Patients with Osteoarthritis of the Hip and Knee Results of a Randomized Controlled Trial JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Bozic, K. J., Belkora, J., Chan, V., Youm, J., Zhou, T., Dupaix, J., Bye, A. N., Braddock, C. H., Chenok, K. E., Huddleston, J. I. 2013; 95A (18): 1633-1639
  • Should Draining Wounds and Sinuses Associated With Hip and Knee Arthroplasties Be Cultured? JOURNAL OF ARTHROPLASTY Tetreault, M. W., Wetters, N. G., Aggarwal, V. K., Moric, M., Segreti, J., Huddleston, J. I., Parvizi, J., Della Valle, C. J. 2013; 28 (8): 133-136
  • Should draining wounds and sinuses associated with hip and knee arthroplasties be cultured? journal of arthroplasty Tetreault, M. W., Wetters, N. G., Aggarwal, V. K., Moric, M., Segreti, J., Huddleston, J. I., Parvizi, J., Della Valle, C. J. 2013; 28 (8): 133-136


    We assessed the utility of culturing draining wounds or sinuses in evaluating periprosthetic joint infection (PJI). Fifty-five patients with a draining wound or sinus after total joint arthroplasty (28 knees, 27 hips) who had not received antibiotics for at least two weeks were prospectively studied. Superficial wound cultures were compared to intra-articular cultures to determine accuracy in isolating infecting organism(s). The superficial cultures were concordant with deep cultures in 26 of 55 cases (47.3%) and were more likely to generate polymicrobial results (27.3% vs. 10.9%; P=0.023). In 23 cases (41.8%), the superficial cultures would have led to a change in antibiotic regimen. Superficial cultures yielded bacterial growth in 8 of the 10 cases (80%) when deep cultures and further work-up suggested the absence of deep infection. Given the potential to misguide diagnosis and treatment, we recommend against obtainment of superficial cultures in patients with a draining wound or sinus following hip or knee arthroplasty.

    View details for DOI 10.1016/j.arth.2013.04.057

    View details for PubMedID 23906868

  • Determinants of time to opioid cessation post-surgery Ruchelli, G., Clay, D., Schmidt, P., Humphreys, K., Trafton, J., Dirbas, F., Giori, N., Goodman, S., Hoang, C., Huddleston, J., Maloney, W., Merritt, R., Miller, M., Shrager, J., Whyte, R., Mackey, S., Carroll, I. CHURCHILL LIVINGSTONE. 2013: S18–S18
  • MI TKA: a risk factor for early revision surgery. journal of knee surgery Mayle, R. E., Graw, B. P., Huddleston, H. G., Woolson, S. T., Goodman, S. B., Huddleston, J. I. 2012; 25 (5): 423-427


    Minimal incision total knee arthroplasty (MI TKA) was developed with the potential to decrease surgical trauma, pain, and recovery time. While this procedure has increased in popularity, some surgeons have questioned its safety and long-term efficacy. In this study 58 consecutive revision total knee arthroplasties (TKAs) (57 patients) performed at one academic medical center from 2006 to 2008 are reviewed. Prospectively collected clinical and radiographic data included: incision length, gender, age, time to revision surgery, and primary diagnosis at time of revision. Of these, 34 knees involving infection and rerevision were excluded. Of the remaining 24 knees, 11 knees that met inclusion criteria had undergone MI TKA. There were no differences between the groups with regard to age, diagnosis, body mass index, and gender. Average time to revision was shorter for the MI TKA patients (29 vs. 65 months, p < 0.032, odds ratio 14.7). Reasons for revision were aseptic loosening (55%), pain/stiffness (27%), malrotation (9%), and instability (9%) in the MI TKA group and aseptic loosening (53%), instability (15%), pain/stiffness (8%), malrotation (8%), combined malrotation and instability (8%), and polyethylene wear/osteolysis (8%) in the traditional TKA group. These data suggest that MI TKA may be a risk factor for early revision.

    View details for DOI 10.1055/s-0032-1313757

    View details for PubMedID 23150354

  • MI TKA: A Risk Factor for Early Revision Surgery JOURNAL OF KNEE SURGERY Mayle, R. E., Graw, B. P., Huddleston, H. G., Woolson, S. T., Goodman, S. B., Huddleston, J. I. 2012; 25 (5): 423-427
  • Advanced Age and Comorbidity Increase the Risk for Adverse Events After Revision Total Hip Arthroplasty JOURNAL OF ARTHROPLASTY Koenig, K., Huddleston, J. I., Huddleston, H., Maloney, W. J., Goodman, S. B. 2012; 27 (7): 1402-1407


    With the institution of quality-assurance parameters in health care, physicians must accurately measure and report the true baseline rates of adverse events (AEs) after complex surgical interventions. To better quantify the risk of AEs for revision total hip arthroplasty (THA), we divided a cohort of 306 patients (322 procedures) into age groups: group I (<65 years, n = 138), group II (65-79 years, n = 119), and group III (?80 years, n = 65). Ninety-day rates of major AE were 9%, 19%, and 34% in the groups, respectively. Group III had an increased chance of experiencing major AE compared with groups I and II. Age and Charlson Comorbidity Index independently predicted major complications, whereas body mass index, sex, and type of revision did not.

    View details for DOI 10.1016/j.arth.2011.11.013

    View details for Web of Science ID 000307317100024

    View details for PubMedID 22245123

  • Heparin-induced thrombocytopenia after total knee arthroplasty, with subsequent adrenal hemorrhage. journal of arthroplasty Chow, V. W., Abnousi, F., Huddleston, J. I., Lin, L. H. 2012; 27 (7): 1413 e15-8


    Heparin-induced thrombocytopenia (HIT) is a life-threatening immune-mediated adverse effect of chemoprophylaxis for venous thromboembolic events. We present the case of a 44-year-old man who developed bilateral adrenal hemorrhage (BAH) as a sequela of HIT after bilateral total knee arthroplasty. In our review of clinical management of HIT-induced BAH, we discuss the 21 published cases of this phenomenon, 14 of which occurred after orthopedic surgery. Given the potentially fatal consequences and the importance of early intervention, physicians should be on the alert for recognizing HIT-induced BAH in patients experiencing shock unresponsive to fluid resuscitation. In addition, chemoprophylaxis with alternative agents such as a synthetic pentasaccharide factor Xa inhibitor and oral direct thrombin inhibitors that are associated with lower risks of HIT in orthopedic patients merits exploration.

    View details for DOI 10.1016/j.arth.2012.01.012

    View details for PubMedID 22397862

  • Commentary: Is the hip bone connected to the spine bone? SPINE JOURNAL Huddleston, J. I., Maloney, W. J. 2012; 12 (5): 370-371


    COMMENTARY ON: Prather H, Van Dillen LR, Kymes SM, et al. Impact of coexistent lumbar spine disorders on clinical outcomes and physician charges associated with total hip arthroplasty. Spine J 2012;12:363-9 (in this issue).

    View details for DOI 10.1016/j.spinee.2012.05.002

    View details for Web of Science ID 000305298300002

    View details for PubMedID 22698149

  • Age and Obesity Are Risk Factors for Adverse Events After Total Hip Arthroplasty Huddleston, J. I., Wang, Y., Uquillas, C., Herndon, J. H., Maloney, W. J. SPRINGER. 2012: 490-496


    Defining the epidemiology of adverse events after THA will aid in the development of strategies to enhance perioperative care.We identified (1) risk factors for adverse events in Medicare beneficiaries while hospitalized after THA and (2) trends in the rates of adverse events.Data were abstracted from medical records of 1809 Medicare beneficiaries who underwent THA from 2002 to 2007. We used the hierarchical generalized linear modeling approach to assess the odds of change in adverse events over time, the association of adverse events with outcomes, and the relationship of adverse events with patient characteristics by modeling the log-odds of adverse events as a function of demographic and clinical variables adjusted for year variable.The overall rate of adverse events was 5.8%; the 30-day mortality rate was 1.00%. Increased age, obesity, and year of procedure were risk factors for experiencing any adverse event. Annual rates of adverse events from 2002 to 2007 were 9.1%, 8.2%, 4.9%, 4.1%, 3.5%, and 3.0%, respectively. Experiencing any adverse event was associated with an increased length of stay and an increased chance of readmission but not with an increased chance of mortality. The annual rate of all adverse events decreased from 2002-2004 to 2005-2007 (odds ratio = 0.83; 95% confidence interval, 0.74-0.92).Older and obese patients should be counseled regarding their increased risk for the development of adverse events after THA. The cause of the decline in the rate of adverse events between two time periods is unclear and warrants further investigation to confirm and identify the cause.

    View details for DOI 10.1007/s11999-011-1967-y

    View details for Web of Science ID 000299056000022

    View details for PubMedID 21796477

  • Decreased Length of Stay After TKA Is Not Associated With Increased Readmission Rates in a National Medicare Sample CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Vorhies, J. S., Wang, Y., Herndon, J. H., Maloney, W. J., Huddleston, J. I. 2012; 470 (1): 166-171


    There is a trend toward decreasing length of hospital stay (LOS) after TKA although it is unclear whether this trend is detrimental to the overall postoperative course. Such information is important for future decisions related to cost containment.We determined whether decreases in LOS after TKA are associated with increases in readmission rates.We retrospectively reviewed the rates and reasons for readmission and LOS for 4057 Medicare TKA patients from 2002 to 2007. We abstracted data from the Medicare Patient Safety Monitoring System. Hierarchical generalized linear modeling was used to assess the odds of changing readmission rates and LOS over time, controlling for changes in patient demographic and clinical variables.The overall readmission rate in the 30 days after discharge was 228/4057 (5.6%). The 10 most common reasons for readmission were congestive heart failure (20.4%), chronic ischemic heart disease (13.9%), cardiac dysrhythmias (12.5%), pneumonia (10.8%), osteoarthrosis (9.4%), general symptoms (7.4%), acute myocardial infarction (7.0%), care involving other specified rehabilitation procedure (6.3%), diabetes mellitus (6.3%), and disorders of fluid, electrolyte, and acid-base balance (5.9%); the top 10 causes did not include venous thromboembolism syndromes. We found no difference in the readmission rate between the periods 2002-2004 (5.5%) and 2005-2007 (5.8%) but a reduction in LOS between the periods 2002-2004 (4.1 ± 2.0 days) and 2005-2007 (3.8 ± 1.7 days).The most common causes for readmission were cardiac-related. A reduction in LOS was not associated with an increase in the readmission rate in this sample. Optimization of cardiac status before discharge and routine primary care physician followup may lead to lower readmission rates.

    View details for DOI 10.1007/s11999-011-1957-0

    View details for Web of Science ID 000298103100021

    View details for PubMedID 21720934

  • Long-Term Comparison of Mobile-Bearing vs Fixed-Bearing Total Knee Arthroplasty JOURNAL OF ARTHROPLASTY Woolson, S. T., Epstein, N. J., Huddleston, J. I. 2011; 26 (8): 1219-1223


    Few published reports have been published regarding a comparison of the long-term outcomes between mobile- (MB) and fixed-bearing component designs for knee arthroplasty. The minimum 10-year clinical and radiologic follow-up of an unselected consecutive series of 89 patients (107 knees) who were randomized to have one of these different designs for primary arthroplasty was done. Twenty-six patients (30 knees) who had a fixed-bearing design and 24 patients (33 knees) who had an MB prosthesis were available for follow-up. Two MB knees were revised for aseptic loosening of a tibial component in one and femoral component fracture in the other. In patients who did not have revision surgery, there were no differences between the groups with respect to mean Knee Society scores, knee flexion, or pain scores.

    View details for DOI 10.1016/j.arth.2011.01.014

    View details for Web of Science ID 000297389100017

    View details for PubMedID 21397453

  • Readmission and Length of Stay After Total Hip Arthroplasty in a National Medicare Sample JOURNAL OF ARTHROPLASTY Vorhies, J. S., Wang, Y., Herndon, J., Maloney, W., Huddleston, J. I. 2011; 26 (6): 119-123


    Evaluation of hospital readmissions after total hip arthroplasty may help improve patient safety and cost reduction. This study investigates the rates and reasons for readmission as well as length of hospital stay (LOS) for 1802 total hip arthroplasty patients from 2002 to 2007. Data were abstracted from the Medicare Patient Safety Monitoring System. The overall 30-day rate of readmission was 6.8%. There was no difference in readmission rate from 2002 to 2004 (7.1%) to 2005 to 2007 (6.3%) (odds ratio, 0.90; 95% confidence interval, 0.63-1.30; P = .58). The overall mean LOS was 4.2 ± 2.2 days. There was a significant reduction in LOS from 2002 to 2004 (4.4 ± 2.5 days) to 2005 to 2007 (3.8 ± 1.7 days) (odds ratio, 1.28; 95% confidence interval, 1.25-1.31; P < .0001). The most common causes for readmission were cardiac related. A reduction in LOS was not associated with an increase in the rate of readmission in this sample. Efforts to optimize cardiac status before discharge may lead to lower rates of readmission in the future.

    View details for DOI 10.1016/j.arth.2011.04.036

    View details for Web of Science ID 000294393000023

    View details for PubMedID 21723700

  • Synovial Tissue-Infiltrating Natural Killer Cells in Osteoarthritis and Periprosthetic Inflammation ARTHRITIS AND RHEUMATISM Huss, R. S., Huddleston, J. I., Goodman, S. B., Butcher, E. C., Zabel, B. A. 2010; 62 (12): 3799-3805


    Infiltrating immune cells play a central role in degenerative joint disease associated with osteoarthritis (OA) and particle-mediated periprosthetic osteolysis. The goal of this study was to characterize a newly identified population of synovial tissue-infiltrating natural killer (NK) cells obtained from patients with OA or patients with periprosthetic joint inflammation.Synovial and interfacial tissue samples were collected from patients with OA who were undergoing primary or revision total joint replacement (TJR) surgery. The histologic features of OA synovium obtained from patients undergoing primary surgery and interfacial tissue obtained from patients undergoing revision surgery were determined by immunohistochemistry and immunofluorescence. Synovial tissue-infiltrating NK cells were evaluated for the expression of surface receptors, using flow cytometry. Chemoattractant and cytokine protein and RNA levels in synovial and interfacial tissue and fluid were assessed by Luminex assay and real-time quantitative polymerase chain reaction. Cytokine production and degranulation by stimulated synovial tissue versus normal blood NK cells were evaluated by intracellular cytokine staining.NK cells comprised nearly 30% of the CD45+ mononuclear cell infiltrate in synovial tissue obtained from patients undergoing primary TJR and from patients undergoing revision TJR. NK cells from both groups expressed CXCR3, CCR5, L-selectin, ?4 integrins, and cutaneous lymphocyte antigen. Synovial fluid from patients undergoing revision surgery contained elevated concentrations of the NK cell attractants CCL4, CCL5, CXCL9, and CXCL10; all levels in synovial fluid obtained from patients undergoing revision surgery were higher than those in synovial fluid from patients undergoing primary surgery. Cytokine-stimulated interferon-? production was significantly impaired in NK cells derived from primary and revision TJRs compared with blood NK cells.NK cells are a principal tissue-infiltrating lymphocyte subset in patients with OA and patients with periprosthetic inflammation and display a quiescent phenotype that is consistent with postactivation exhaustion.

    View details for DOI 10.1002/art.27751

    View details for Web of Science ID 000285210200034

    View details for PubMedID 20848566

  • Use and Cost-Effectiveness of Intraoperative Acid-Fast Bacilli and Fungal Cultures in Assessing Infection of Joint Arthroplasties JOURNAL OF ARTHROPLASTY Wadey, V. M., Huddleston, J. I., Goodman, S. B., Schurman, D. J., Maloney, W. J., Baron, E. J. 2010; 25 (8): 1231-1234


    The objective of this study is to determine a protocol for collecting acid-fast bacilli (AFB) and fungal intraoperative cultures during orthopedic procedures. An observational study was undertaken. Four hundred forty-six AFB cultures and 486 fungal cultures were processed over a 2-year period. The number of positive cultures was determined. A protocol specific to handling these types of specimens was developed. Cost analysis was completed to determine both the time and money saved if the new protocol was implemented. The infrequency of positive AFB and fungal cultures in this study suggests that it is only necessary to routinely request AFB and fungal cultures on 1 of 5 samples. Implementation of this protocol has potential to lead to substantial cost reduction and resource savings without diminishing patient outcomes.

    View details for DOI 10.1016/j.arth.2009.08.018

    View details for Web of Science ID 000284749500009

    View details for PubMedID 19879728

  • Repair of a deficient abductor mechanism with Achilles tendon allograft after total hip replacement. journal of bone and joint surgery. American volume Fehm, M. N., Huddleston, J. I., Burke, D. W., Geller, J. A., Malchau, H. 2010; 92 (13): 2305-2311


    Abductor mechanism insufficiency after total hip arthroplasty is a rare but debilitating problem. The diagnosis is difficult, and when the condition is recognized there are few successful treatment options. The purpose of this study was to review our experience with a surgical technique involving use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to reconstruct a deficient abductor mechanism after total hip arthroplasty.From 2003 to 2006, we performed seven abductor reconstructions with an Achilles tendon allograft in patients with abductor deficiency after total hip arthroplasty. At a mean of twenty-nine months after the total hip arthroplasty, all seven patients had symptoms of lateral hip pain and abductor muscle weakness as demonstrated by a Trendelenburg test. The abductor tendon rupture was diagnosed on the basis of an arthrogram and was confirmed at surgery.Before the reconstruction, the average Harris hip score was 34.7 points and the average pain score was 11.4 points. After a minimum duration of follow-up of twenty-four months, the average Harris hip score was 85.9 points and the average pain score was 38.9 points.Abductor reconstruction with an Achilles tendon allograft with a calcaneal bone block attached to the greater trochanter can produce substantial relief of pain, increased abductor muscle strength, decreased limp, and improvements in the Trendelenburg sign and in function at the time of early follow-up.

    View details for DOI 10.2106/JBJS.I.01011

    View details for PubMedID 20926725

  • Repair of a Deficient Abductor Mechanism with Achilles Tendon Allograft After Total Hip Replacement JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Fehm, M. N., Huddleston, J. I., Burke, D. W., Geller, J. A., Malchau, H. 2010; 92A (13): 2305-2311
  • Candida infection in total knee arthroplasty with successful reimplantation. The journal of knee surgery Graw, B., Woolson, S., Huddleston, J. I. 2010; 23 (3): 169-174


    Fungal infections associated with prosthetic joints are uncommon. The first case report describes a woman with insidious onset of a candidal infection of a revision total knee arthroplasty. After multiple joint debridements and prolonged antibacterial and antifungal therapy, she had a successful reimplantation of a knee prosthesis. The second case report concerns a man who had a primary cemented total knee arthroplasty that became infected with Candida albicans. He underwent resection arthroplasty with eventual replant without recurrence at 20 years. Although resection arthroplasty should be maintained as the gold standard in the surgical treatment of this problem, the first case shows a successful short-term outcome ofreimplantation of a patient with fungal infection of long-stemmed, revision total knee replacement. It also shows a treatment failure with fluconazole that was cured by voriconazole and caspofungin, two more recently developed antifungal agents.

    View details for PubMedID 21329258

  • Minimal Incision Surgery as a Risk Factor for Early Failure of Total Hip Arthroplasty CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Graw, B. P., Woolson, S. T., Huddleston, H. G., Goodman, S. B., Huddleston, J. I. 2010; 468 (9): 2372-2376


    Minimal incision total hip arthroplasty (MI THA) techniques were developed to decrease postoperative pain and recovery time. Although these techniques have increased in popularity, the long-term survivorship of these procedures is unknown.We therefore investigated whether the time to revision in our referral practice was shorter for patients who underwent primary MI THA compared to primary traditional THA.We retrospectively reviewed 46 revision THAs performed during a 3-year period. We excluded revisions performed for infection and rerevisions. Patients with incisions less than or equal to 10 cm were defined as having had MI THA. Fifteen of the 46 patients (33%) had undergone primary MI THA. At the time of primary index THA, the mean ages of the MI and non-MI patients were 65 years and 55 years, respectively.The mean time to revision was 1.4 years for the MI patients compared with 14.7 years for the non-MI patients. Twelve of the 15 patients having MI THA required revision within 2 years of primary THA compared to 4 of the 31 patients without MI surgery (OR = 26.5, 95% CI 4.4-160.0). There were no differences between the groups with regard to age, gender, or body mass index. The most common reasons for revision in the MI THA group were intraoperative fracture and failure of femoral component osseointegration.Our data suggest MI THA may be a risk factor for early revision surgery and the long-term survival therefore may be lower than that for non-MI surgery.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

    View details for DOI 10.1007/s11999-010-1300-1

    View details for Web of Science ID 000280594200011

    View details for PubMedID 20352391

  • Patellar Management in Revision Total Knee Arthroplasty JOURNAL OF ARTHROPLASTY Patil, N., Lee, K., Huddleston, J. I., Harris, A. H., Goodman, S. B. 2010; 25 (4): 589-593


    The management of the patella during revision total knee arthroplasty (TKA) depends on the indication for revision, the type and stability of the patellar component in place, and availability of bone stock. We prospectively compared the clinical outcome and satisfaction rates in revision TKA patients managed with patellar resurfacing (n = 13, group I) to retention of the patellar component (n = 22, group II) or patelloplasty (n = 11, group III) at a minimum follow-up of 2 years. There were no differences in the improvement of Knee Society Scores, Short-Form 36 Scores, and satisfaction rates between the groups. There were no revision surgeries for patellar component failure or patellar fractures. Satisfactory results can be achieved using a variety of methods of patellar management in revision TKA by individualizing the treatment modality depending on the clinical scenario.

    View details for DOI 10.1016/j.arth.2009.04.009

    View details for Web of Science ID 000278905300016

    View details for PubMedID 19493648

  • Aseptic versus septic revision total knee arthroplasty: Patient satisfaction, outcome and quality of life improvement KNEE Patil, N., Lee, K., Huddleston, J. I., Harris, A. H., Goodman, S. B. 2010; 17 (3): 200-203


    We prospectively compared the clinical outcomes and patient satisfaction rates of aseptic (n=30) versus septic revision TKA (n=15) at a mean follow-up of 40 months. We hypothesized that the clinical results of septic revision TKA would be inferior to aseptic revision TKA. The indication for revision in aseptic group was stiffness in 11 patients, aseptic loosening in 13, patellar loosening or maltracking in 6 patients. Patients operated for infection had better post-operative Knee Society Scores (KSS), Function Scores and SF-36 Mental Scores than aseptic group but there were no significant differences in the satisfaction rates. Patients operated for infection had more improvement in their KSS (p=0.004) and Function Scores (p=0.02) than patients revised for stiffness. Moreover, patients operated on for patellar problems had higher satisfaction rates than patients revised for stiffness (p=0.01) or aseptic loosening (p=0.01). Thus, patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. However, in the aseptic group, revision TKA for stiffness was associated with the poorest outcomes. The indication for aseptic revision is an important variable when discussing treatment and outcome with patients.

    View details for DOI 10.1016/j.knee.2009.09.001

    View details for Web of Science ID 000277698100005

    View details for PubMedID 19875297

  • Hylamer vs Conventional Polyethylene in Primary Total Hip Arthroplasty: A Long-Term Case-Control Study of Wear Rates and Osteolysis JOURNAL OF ARTHROPLASTY Huddleston, J. I., Harris, A. H., Atienza, C. A., Woolson, S. T. 2010; 25 (2): 203-207


    The long-term results of Hylamer implants have not been reported previously. Clinical and radiographic results of a consecutive series of 43 patients (45 hips) who had primary total hip arthroplasty using Hylamer liners were compared with those of 37 patients (43 hips) who had conventional liners after 10-year follow-up. The linear wear rates for Hylamer and conventional polyethylene acetabular liners were 0.21 and 0.20 mm/y, respectively. The number of pelvic osteolytic lesions and their size detected on plain radiographs were significantly greater for Hylamer liners. Seven Hylamer hips were revised or are pending revision for osteolysis (16%) compared with 1 control hip. Close radiographic surveillance of patients who have Hylamer liners and evidence of osteolysis found on plain radiographs is warranted.

    View details for DOI 10.1016/j.arth.2009.02.006

    View details for Web of Science ID 000277580900006

    View details for PubMedID 19264443

  • Primary Total Hip Arthroplasty Using an Anterior Approach and a Fracture Table Short-term Results From a Community Hospital JOURNAL OF ARTHROPLASTY Woolson, S. T., Pouliot, M. A., Huddleston, J. I. 2009; 24 (7): 999-1005


    There are no data regarding the efficacy and safety of minimally invasive hip arthroplasty technique performed by community practice orthopedists. The early clinical and radiographic results of primary total hip arthroplasty using a minimally invasive anterior approach to the hip performed on a fracture table were studied. Two hundred thirty-one consecutive patients (247 hips) of 5 community practice surgeons were studied. The average surgical time (164 minutes) and estimated blood loss (858 mL) were more than double, and the major complication rate (9%) was 6 times that reported by an innovator of the procedure. However, no postoperative dislocations occurred. Adequate training is critical to reduce the risk of complications during the learning experience of minimally invasive hip arthroplasty procedures by community practice surgeons.

    View details for DOI 10.1016/j.arth.2009.04.001

    View details for Web of Science ID 000270764600001

    View details for PubMedID 19493651

  • Early Catastrophic Failure of a Porous-Coated Acetabular Cup due to Bead Shedding. A Case Report HIP INTERNATIONAL Hsu, A. R., Vaughn, Z., Huddleston, J. I. 2009; 19 (4): 392-395


    We present a patient in whom an uncemented porous-coated acetabular cup underwent early catastrophic failure due to debonding and was successfully managed with a revision total hip arthroplasty. Early bead shedding of an acetabular cup leading to a sudden component failure requiring revision surgery is a rare event.

    View details for Web of Science ID 000275580700016

    View details for PubMedID 20041389

  • Adverse Events After Total Knee Arthroplasty A National Medicare Study JOURNAL OF ARTHROPLASTY Huddleston, J. I., Maloney, W. J., Wang, Y., Verzier, N., Hunt, D. R., Herndon, J. H. 2009; 24 (6): 95-100


    Adverse events from 2033 total knee arthroplasty patients were documented by nonphysician abstractors. The annual rate of adverse events from 2002 to 2004 was 9.2%, 6.4%, and 5.8%, respectively. Congestive heart failure (odds ratio, 2.1; 95% confidence interval, 1.2-3.5; P < .01) and chronic obstructive pulmonary disease (odds ratio, 1.8; 95% confidence interval, 1.2-2.7; P < .01) were associated with a significantly increased risk of experiencing any adverse event during the index hospitalization. The 30-day postprocedure rate of readmission for all causes was 5.5%. Experiencing an adverse event during the index hospitalization increased the length of stay (P < .001). The rate of symptomatic venous thromboembolism 30 days postprocedure was 1.7%. The 30-day postprocedure mortality rate was 0.3%. Experiencing any adverse event was associated with an increased 30-day postprocedure mortality (P < .001). Compared with previous studies of Medicare claims, these data reveal a substantial decrease in the mortality rate, an increased readmission rate, and no substantial change in the rate of venous thromboembolism.

    View details for DOI 10.1016/j.arth.2009.05.001

    View details for Web of Science ID 000269607800020

    View details for PubMedID 19577884

  • 2009 Marshall Urist Young Investigator Award: how often do patients with high-flex total knee arthroplasty use high flexion? Clinical orthopaedics and related research Huddleston, J. I., Scarborough, D. M., Goldvasser, D., Freiberg, A. A., Malchau, H. 2009; 467 (7): 1898-1906


    Although high-flexion TKA designs aim to safely accommodate deep flexion, it is unknown how often patients use deep flexion outside the laboratory. We used a validated smart-activity monitor to document the prevalence of knee flexion greater than 90 degrees in 20 consecutive patients (21 knees) who had high-flexion TKAs, at a minimum of 2 years' followup. Patients wore the device continuously for a mean of 35.7 +/- 0.5 hours. The 21 knees flexed more than 90 degrees for an average of 10 +/- 3.8 minutes (0.5%). Activities performed with flexion greater than 90 degrees were, on average, 70% in single-limb stance, 12% moving from sitting to standing, 8% walking, 7% moving from standing to reclining, 2% stepping, 0.9% moving from lying to standing, and 0.1% running. Eight knees flexed greater than 120 degrees for an average of 2.2 minutes (range, 0.2-15 minutes), or 0.1% of the testing time. Activities performed with flexion greater than 120 degrees were, on average, 90% in single-limb stance, 6% moving from sitting to standing, 3% walking, 0.6% moving from standing to reclining, 0.3% stepping, and 0.1% moving from lying to standing. Peak flexion used at any time during testing was, on average, 84% +/- 11% of maximum postoperative flexion (125 degrees +/- 12 degrees). These patients rarely used deep flexion.Level IV, therapeutic study.

    View details for DOI 10.1007/s11999-009-0874-y

    View details for PubMedID 19421828

  • How Often Do Patients with High-Flex Total Knee Arthroplasty Use High Flexion? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Huddleston, J. I., Scarborough, D. M., Goldvasser, D., Freiberg, A. A., Malchau, H. 2009; 467 (7): 1898-1906
  • Early outcome of a modular femoral component in revision total hip arthroplasty JOURNAL OF ARTHROPLASTY Kang, M. N., Huddleston, J. I., Hwang, K., Imrie, S., Goodman, S. B. 2008; 23 (2): 220-225


    Forty-six hips in 42 patients underwent revision surgery with a modular femoral component (ZMR; Zimmer, Warsaw, Ind). Thirty-nine hips with 2 to 5 years' follow-up were evaluated radiographically and clinically by the Harris hip score and WOMAC pain/stiffness/function scores. The Harris hip score improved from 47.4 to 72.3 (P<.001), with significant improvements in the WOMAC pain/stiffness/function scores. The mean subsidence was 4.4 mm, with 5 hips demonstrating significant subsidence of more than 5 mm. Four hips required reoperation, 1 due to failure of the femoral component. No early complications were encountered regarding the modular junction. Modular, cementless, extensively porous, coated femoral components have demonstrated early clinical and radiographic success. Distal intramedullary fit helps ensure initial stability; proximal modularity further maximizes fit while optimizing hip offset and length.

    View details for DOI 10.1016/j.arth.2007.03.006

    View details for Web of Science ID 000253649200011

    View details for PubMedID 18280416

  • How have alternative bearings (such as metal-on-metal, highly cross-linked polyethylene, and ceramic-on-ceramic) affected the prevention and treatment of osteolysis? JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Callaghan, J. J., Cuckler, J. M., Huddleston, J. I., Galante, J. O. 2008; 16: S33-S38


    Osteolysis is a multifactorial process dependent on surgical technique, implant design, patient factors, and material composition. Alternative bearing surfaces, such as highly cross-linked polyethylene, ceramic-on-ceramic, and metal-on-metal articular surfaces, have been introduced in an attempt to reduce wear and osteolysis following total hip arthroplasty. Intermediate-term follow-up data available suggest that the prevalence and severity of osteolysis may be reduced with these materials compared with conventional metal-on-polyethylene bearing surface couples. However, long-term data are presently unavailable; the future performance of these bearings awaits clinical validation.

    View details for Web of Science ID 000257474600008

    View details for PubMedID 18612011

  • Modulation of allograft incorporation by growth factors over a prolonged continuous infusion of duration in vivo BONE Ma, T., Gutnick, J., Salazar, B., Larsen, M. D., Suenaga, E., Zilber, S., Huang, Z., Huddleston, J., Smith, R. L., Goodman, S. 2007; 41 (3): 386-392


    Morselized cancellous allograft bone is frequently used in the reconstruction of bone defects in cases of revision total joint replacement, trauma, spine fusion and treated infection. However, the initial lack of viable bone cells in morselized allograft bone significantly slows the process of graft incorporation compared to autograft bone. This study examined the effects of prolonged local infusion of the growth factors bone morphogenic protein-7 (BMP-7 or OP-1) and fibroblast growth factor-2 (FGF-2 or basic FGF) in the process of allograft incorporation using a rabbit tibial chamber model. New bone formation was evaluated by two indices, the activity of alkaline phosphatase and the level of birefringence. The markers of osteoclast-like cells were also measured. Without the infusion of the growth factors, lower levels of new bone formation were observed in the allograft group, compared to the autograft group. Infusion of growth factors FGF-2 and OP-1, singly or in combination, for 4 weeks, diminished this difference. The numbers of osteoclast-like cells were much higher in the allograft group before the growth factors were delivered. The infusion of FGF, singly, diminished this difference. However, the infusion of OP-1 or the combination of FGF and OP-1 did not decrease the number of osteoclast-like cells to a level comparable to autograft only. Local infusion of growth factors appears to be a useful adjunct to promote the incorporation of allograft bone in vivo.

    View details for DOI 10.1016/j.bone.2007.05.015

    View details for Web of Science ID 000248898600012

    View details for PubMedID 17613298

  • Ambulatory measurement of knee motion and physical activity: preliminary evaluation of a smart activity monitor JOURNAL OF NEUROENGINEERING AND REHABILITATION Huddleston, J., Alaiti, A., Goldvasser, D., Scarborough, D., Freiberg, A., Rubash, H., Malchau, H., Harris, W., Krebs, D. 2006; 3


    There is currently a paucity of devices available for continuous, long-term monitoring of human joint motion. Non-invasive, inexpensive devices capable of recording human activity and joint motion have many applications for medical research. Such a device could be used to quantify range of motion outside the gait laboratory. The purpose of this study was to test the accuracy of the modified Intelligent Device for Energy Expenditure and Activity (IDEEA) in measuring knee flexion angles, to detect different physical activities, and to quantify how often healthy subjects use deep knee flexion in the ambulatory setting.We compared Biomotion Laboratory (BML) "gold standard" data to simultaneous IDEEA measures of knee motion and gait, step up/down, and stair descent in 5 healthy subjects. In addition, we used a series of choreographed physical activities outside the BML to confirm the IDEEA's ability to accurately measure 7 commonly-performed physical activities. Subjects then continued data collection during ordinary activities outside the gait laboratory.Pooled correlations between the BML and IDEEA knee flexion angles were .97 +/- .03 for step up/down, .98 +/- .02 for stair descent, and .98 +/- .01 for gait. In the BML protocol, the IDEEA accurately identified gait, but was less accurate in identifying step up/down and stair descent. During sampling outside the BML, the IDEEA accurately detected walking, running, stair ascent, stair descent, standing, lying, and sitting. On average, subjects flexed their knees >120 degrees for 0.17% of their data collection periods outside the BML.The modified IDEEA system is a useful clinical tool for evaluating knee motion and multiple physical activities in the ambulatory setting. These five healthy subjects rarely flexed their knees >120 degrees.

    View details for Web of Science ID 000251258600001

    View details for PubMedID 16970818

  • Biomotion community-wearable human activity monitor: Total knee replacement and healthy control subjects BSN 2006: INTERNATIONAL WORKSHOP ON WEARABLE AND IMPLANTABLE BODY SENSOR NETWORKS, PROCEEDINGS Krebs, D. E., Huddleston, J. I., Goldvasser, D., Scarborough, D. M., Harris, W. H., Malchau, H. 2006: 109-112
  • Femoral Alignment Revision Total Knee Arthroplasty Huddleston JI, Gobezie R, Rubash HE 2005
  • Zone 4 femoral radiolucent lines in hybrid versus cemented total knee arthroplasties: are they clinically significant? Clinical Orthopaedics and Related Research Huddleston JI, Wiley J, Scott RD 2005; 441: 334-339
  • Determination of neutral tibial rotational alignment in rotating platform TKA Clinical Orthopaedics and Related research Huddleston JI, Scott RD, Wimberley DW 2005; 440: 101-106
  • A comparison of subjective, psychomotor and physiologic effects of a novel muscarinic analgesic, LY 297802 tartrate, and oral morphine in occasional drug users Drug and Alcohol Dependence Petry NM, Bickel WK, Huddleston J, Tzanis E, Badger GJ 1998; 50: 29-36